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JU INSIGHT: National Adherence to Guidelines for Antimicrobial Prophylaxis for Patients Undergoing Radical Cystectomy

By: Megan Prunty, MD; Stephen Rhodes, PhD; Marco-Jose Rivero, MD; Michael Callegari, MD, MBA; Erin Jesse, MD; Camilo Arenas-Gallo, MD; Aaron Brant, MD; Adam Calaway, MD, MPH; Douglas Scherr, MD; Jonathan E. Shoag, MD, PhD | Posted on: 16 Feb 2023

Prunty M, Rhodes S, Rivero M-J, et al. National adherence to guidelines for antimicrobial prophylaxis for patients undergoing radical cystectomy. J Urol. 2023;209(2):329-336.

Study Need and Importance

The American Urological Association recommends antimicrobial prophylaxis to prevent infectious complications in patients undergoing radical cystectomy with ileal conduit for bladder cancer. Here, we evaluate adherence to antimicrobial prophylaxis guidelines from 2015-2020 using a large national database. In addition, we evaluated the association between antimicrobial use and postoperative infection during the index admission after cystectomy.

What We Found

Among 6,708 patients undergoing cystectomy with ileal conduit, only 28% were given prophylaxis according to AUA guidelines; 1.8% of patients received an antifungal and 37% received extended duration prophylaxis beyond postoperative day 1 (see Figure). Patients who received guidelines-based prophylaxis were less likely to be diagnosed with a urinary tract infection, pyelonephritis, bacterial infection, or pneumonia. After adjusting for age, race, insurance, hospital, and provider characteristics, nonguideline antibiotic prophylaxis was associated with increased odds of infectious events.

Figure. Trends in all antibiotic use over time for radical cystectomy with ileal conduit based on antibiotic class. Over time, 1st and 2nd generation (Gen) cephalosporins are consistently the most commonly administered antibiotics.

Limitations

This retrospective study uses the Premier Healthcare Database, therefore selection and measurement biases exist. The database queries are limited to conditions and medications coded for billing purposes and are subject to coding errors and misclassification. We are unable to capture data on preoperative urine cultures or oral antibiotics administered on an outpatient basis to determine the reason for deviating from guidelines.

Interpretation for Patient Care

Most patients do not receive guideline-recommended antibiotic prophylaxis when undergoing radical cystectomy with conduit, largely because patients receive antibiotics longer than the guidelines recommended. We found that guideline-based prophylaxis was associated with a 25% decrease in the odds of infectious complications. These data support the current AUA guidelines and suggest the need for outreach to improve guideline adherence.

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